Download Rapid Access Chest Pain Clinic Referral Form

King’s College Hospital NHS Foundation Trust
King’s College Hospital
Denmark Hill
London SE5 9RS
Tel: 020 3299 9000
Clinic Direct Telephone No: 020 3299 3992/3855
Rapid Access Chest Pain Clinic
GP Referral Form
REFERRAL CRITERIA
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Exertional chest pain suggestive of new onset angina within the last 2 months
Patients reviewed by a Cardiologist within the last five years may be accepted.
Patients with already established IHD should be referred to General Cardiology.
Patients suspected of having Acute MI or Unstable Angina should be referred to
A&E.
Please fill in ALL sections of the form and email to: [email protected]
Incomplete forms will be returned to you to complete prior to any
appointment being given
General Practitioner
Dr :
Patient Details
NHS No:
Surname:
Address:
Forename:
Address:
Postcode:
Tel No:
Practice Email Address:
Home Tel:
Work Tel:
Sex: M( ) F ( )
Date of Birth:
Presenting complaint
Please tick
Chest pain
Equivalents such as breathlessness should be considered particularly in diabetic patients.
Criteria of chest pain
Please specify
Site …………………………………………
Radiation …………………………………….
Relation to Effort ………………………. Duration …………………………………
Character: (please indicate) Tight/squeezing/constricting
Other:………………………………………..
Possible other causes of chest pain e.g. Hiatus hernia, recent chest infection Yes / No
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Specify ………………………………
Vascular Risk Factors
Please tick
Smoker (Ex /Current)
Diabetes
Hyperlipidaemia
Family history of premature coronary artery disease
Hypertension
If Yes, is it controlled?
Other current medical conditions e.g. upper GIT disease, pulmonary disease, please specify
…………………………………………………………..
Medications :…………………………………………………………………………………………………
Past Medical History:………………………………………………………………………………………….
Ability to perform treadmill test:
YES
NO
On examination:
BP
Pulse
Tenderness at the site of pain
Yes
No
Presence of systolic murmur
Yes
No
Investigations
Recent resting ECG
(If yes, please specify and if possible fax with referral)
Rhythm
Bundle Branch Block
ST – T Wave changes
Recent Lipid profile
(If yes, please specify)
Total Cholesterol………….., LDL…….…, HDL……….…, Triglycerides………...
Management
Please tick
Start Aspirin and GTN spray in highly suspicious patients
Chest x-ray if yes, reported as.
Blood Test already ordered to check fasting lipids
FBC
blood glucose
U&E’s
LFT’s
(Please indicate if ordered, and where possible fax results to clinic)
Name: ………………………………………………………….
Signature………………………………………………………… Date……………………………………
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